Meckel’s Diverticulum
Submitted by Denise Drohobyczer MS IV

 

General Considerations “Rule of 2”

  • Most common congenital anomaly of GI tract
    • 2% of population, M=F
  • Within 2 feet proximal to ileocecal valve
  • 2 inches long, 2 cm wide
  • 2 types of heterotopic mucosa
  • Symptomatic in 2%
    • M>F (2:1)
    • Children > adults; often < 2 years old

Embryology and Pathology

  • Incomplete atrophy of omphalomesenteric (vitelline) duct
  • True diverticulum on anti-mesenteric border of ileum
  • 50% contain heterotopic mucosa
    • Most often gastric (50%) and pancreatic (16%)

Complications and Clinical Findings

  • Hematochezia (~40% of complications)
    • Most common complication in children
    • Heterotopic gastric mucosa ® ulceration and hemorrhage
    • Occult blood loss and iron deficiency anemia (adults)
  • Small bowel obstruction (~35%)
    • Most common complication in adults
    • Abdominal guarding and distension, vomiting, obstipation
    • Causes: Volvulus (with persistent fibrous band), torsion, foreign body, Littre’s Hernia (inclusion in hernia sac), inversion ® intussusception
  • Diverticulitis (~17%)
    • Second most common complication in adults
    • RLQ or periumbilical acute abdominal pain
    • Can result in perforation
  • Enteroliths (~10%)
  • Neoplasia (~3%)
    • Most often carcinoid (M>F)

Imaging Findings

  • Abdominal Film, non-specific:
    • Enteroliths, small bowel obstruction, perforation
  • Abdominal CT
    • Diverticulum off distal ileum, small bowel obstruction, intussusception, perforation, diverticulitis, necrosis, enteroliths or inversion of tic
  • Sonography
    • Obstruction, inversion and intussusception
  • Enteroclysis
    • “Triradiate” fold pattern
      • Junction of omphalomesenteric duct and ileum
    • Rugal pattern like stomach(heterotopic gastric tissue)
  • Meckel’s scan (Technetium-99m pertechnetate scintigraphy)
    • Gastric mucosa absorbs and secretes radioactive isotope
    • “Hot spot” in RLQ- most commonly
    • Gold standard for hemorrhagic diverticula
      • 95% specific in children, 60% specific in adults
  • Angiography
    • Visualization of remnant omphalomesenteric (vitellointestinal) artery
      • Off distal ileal branch of superior mesenteric artery
      • Vascular blush (ischemia)

Differential Diagnosis

  • Appendicitis, colonic diverticulitis, acute mesenteric lymphadenitis
  • Single small intestinal diverticulum
  • Communicating enteric duplication
  • Pseudosacculations (Crohn’s Disease)
  • Cavitating malignancies (lymphoma, GIST)

Treatment

  • Surgical excision if symptomatic
  • Prophylactic removal  is controversial

 

 


Meckel's Diverticulum.
Reflux into the small bowel has occurred during a single-contrast barium enema examination. Black arrow points to Meckel's diverticulum arising from small bowel near terminal ileum.
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Levy AD, Hobbs, CM.  Meckel Diverticulum: Radiologic Features with Pathologic Correlation.  Radiographics. 2004; 24: 565-587.

O’Neill, J, Grosfeld, J.  Principles of Pediatric Surgery.  Mosby, 2003.